Complicated cases
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Complicated cases. David Fletcher, MD Department of Medicine University of Toronto. CASE 1. 54 yr /o man HIV positive 8 yrs ago Tenofovir /FTC/RTV/ Atazanavir x 4 yrs Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/ wt CD4 320 HIV Viral Load<40. CASE 1.

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David Fletcher, MD Department of Medicine University of Toronto

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David fletcher md department of medicine university of toronto

Complicated cases

David Fletcher, MDDepartment of MedicineUniversity of Toronto


Case 1

CASE 1

  • 54 yr/o man

  • HIV positive 8 yrs ago

    • Tenofovir/FTC/RTV/Atazanavirx 4 yrs

    • Previously documented NNRTI resistance with Y181C, G190A,and mixed m184v/wt

    • CD4 320 HIV Viral Load<40


Case 11

CASE 1

  • Genotype 1a Hepatitis C biopsy proven cirrhosis

  • Compensated and clinically stable

    • Previous therapy in 2009 with Peg INF/1200mg RBV daily resulted in a null response by history from the patient


Case 12

CASE 1

Patient is interested in a retrial of therapy for Hepatitis C with the new direct acting antiviral agents

  • Would you offer treatment?

  • Chance of cure?

  • Which 3rd agent would you choose and why?

  • Does patient’s antiretroviral history play a role in 3rd agent choice?

  • Is there a role for a 4 week lead in here regardless of agent chosen and if so…why?


Case 13

CASE 1

It was decided to move forwards with Peg INF/ 1200mg RBV/Telaprevir

  • Is it necessary to change current ARVs?

  • Would it be necessary to change ARVs if Boceprevir was chosen?...to what?


Case 14

CASE 1

Peg INF/1200mg RBV/Telaprevir…no lead in performed

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Would you continue?

  • Are you concerned about the result?

  • When would you do the next HCVRNA?


Case 15

CASE1

It was decided to continue with Peg INF/1200mg RBV/Telaprevir and HCVRNA rechecked

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12

  • Would you continue?


Case 16

CASE 1

Peg INF/1200mg RBV/Telaprevir

  • Week 0 HB 140

  • Week 2 HB 125

  • Week 4 HB 109

  • Week 6 HB 99…symptomatic

  • How would you manage anemia?


Case 17

CASE 1

Peg INF/600mgRBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12 HB 99 (symptoms)

  • Week 8 HCVRNA <12 HB 98 (less symptomatic)

  • What would you do?

  • How would you further manage anemia


Case 18

CASE 1

Peg INF/600mg RBV/Telaprevir

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 6 HCVRNA <12

  • Week 8 HCVRNA <12

  • Week 12 HCVRNA detectable but <12 HB 103

  • What would you do?

  • When would you do your next HCVRNA?


Case 19

CASE 1

Peg INF/RBV re-increased to 1200mg

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but <12

  • Week 8 HCVRNA <12

  • Week 12 HCVRNA detectable but <12

  • Week 14 HCVRNA <12 HB 101

  • What would you do?


Case 110

CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but<12

  • Week 12 HCVRNA detectable but <12

  • Week 14 HCVRNA <12 HB 101

  • Week 24 HCVRNA <12 HB 105

  • How much longer would you treat?

  • When would you do your next HCVRNA?


Case 111

CASE 1

Peg INF/1200mg RBV

  • Week 0 HCVRNA 3.7 x 10e7

  • Week 4 HCVRNA detectable but <12

  • Week 12 HCVRNA detectable but <12

  • Week 24 HCVRNA <12

  • Week 36 HCVRNA <12

  • Week 48 HCVRNA <12

  • Are we finished therapy?


Case 112

CASE 1

An additional 24 weeks of PEG INF/RBV (for a total of 72 weeks of therapy) was offered to the patient given the existence of cirrhosis and ?slow HCVRNA clearance as evidenced by a detectable HCVRNA at week 4 and 12

Week 12 and 24 HCVRNA post 72 weeks of therapy were undetectable!


Case 2

CASE 2

  • 52 yo man

  • HIV positive 5 yrs ago

    • CAD with previous MI 3 yrs ago/Hypertensive/Hypothyroidism

  • Tenofovir/FTC/Raltegravir x 4 yrs

    • CD4 700 HIV Viral Load<40


Case 21

CASE 2

  • Hypercholesterolemia and Hypertriglyceridemia on combination therapy with Atorvastatin 80mg/day and Fenofibrate 145mg/day

  • Hypertension controlled on Amlodipine 10mg/day

  • Hypothyroidism controlled on 0.125 mg L-Thyroxine


Case 22

CASE 2

  • Genotype 1a chronic hepatitis C

  • Naïve to therapy

  • F2-3/4 scarring

  • Ready to start triple therapy with PEG INF/RBV/Boceprevir

  • Atorvastatin decreased to 40mg/day

  • Baseline HCVRNA 1.66X10E6


Case 23

CASE 2

  • Week 0 HCVRNA 1.66x10E6

  • Week 4 HCVRNA (lead in)2.37x 10E2

  • Week 8 HCVRNA <12

  • At week 10 begins to feel tired/weak/constipated/muscle cramping

  • TSH noted to be 18.91…L-T4 increased to 0.15mg/d in response


Case 24

CASE 2

  • At week 11 notes increasingly prominent myalgias, more predominant post interferon injection but lasting all week long as opposed to a few hrs post injection, along with increasing weakness

  • Hb stable at 105g/l over last few weeks with RBV dose reduction to 600mg/d

  • AST noted to be increasing while ALT has been normalizing over the last few weeks…also increasing swelling of ankles

    • ?Cause…Hepatic Decompensation?


Case 25

CASE 2

  • CK measured at 83,700

  • BP noted to be low at 90/55 and swelling of ankles worsened now to mid calf…no ascites noted clinically

  • Cause?


Case 26

CASE 2

  • Atorvastatin and Fenofibrate discontinued!!!

  • CK fell over the next few weeks as did AST

  • The symptomatic myalgias and weakness improved over the subsequent month

  • Amlodipine discontinued…BP normalized to 130/80 and ankle swelling disappeared over the next month


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